Provider Demographics
NPI:1528039088
Name:VESTAL, LANCE EDWARD (OT)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:EDWARD
Last Name:VESTAL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 NW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-273-1141
Mailing Address - Fax:479-273-3762
Practice Address - Street 1:3625 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756
Practice Address - Country:US
Practice Address - Phone:479-631-3955
Practice Address - Fax:479-631-0152
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00139314OtherRRMC
AR5U867B720Medicare PIN